4 July 2018
There has been a great deal of progress in lung health since the establishment of the NHS, and as a specialist in chronic obstructive pulmonary disease (COPD), the umbrella term for conditions which include emphysema and bronchitis, I have witnessed some of them during my career.
Public health action, such as tackling smoking and pollution, known factors that can cause or exacerbate chronic obstructive pulmonary disease (COPD) – have had a big part to play in this.
So, too have other aspects of the welfare state. Reduction in poverty and improvement in public housing meant that children’s lungs could develop in a healthier environment. The seeds of adult lung disease are often sown in childhood.
When the NHS came into being after the Second World War, tobacco use was extremely common, especially among men, with more than 80 per cent smoking.
In earlier times you would see spittoons on trains and railway stations where people would spit phlegm that came about as result of bronchitis and other smoking-related problems. Pollution was a big problem– culminating in London’s great smog of 1952.
Smog includes pollutants which irritate the respiratory system. Pollution can cause lung disease and also worsen symptoms, causing acute attacks in people who already have lung conditions like asthma or COPD.
The Clean Air Act came into being in 1956 – this was an acknowledgement of the dangers of smog to respiratory health.
It wasn’t unusual for people to die young from smoking-related diseases, such as cancer and heart disease – when you consider celebrities of that era, Nat King Cole died from lung cancer in his mid-40s. Errol Flynn died from a heart attack at 50. COPD is a progressive disease - the average age at which COPD is diagnosed in the UK is 67, and it rarely affects people under 40.
The effect of stopping smoking on risk of heart disease and cancer is more immediate. As life expectancy has increased so COPD has become more common, a pattern seen across the world, where COPD is now the third leading cause of death globally.
In the UK there are now more than 1.3 million people with a diagnosis of COPD.
Treatment for COPD
The tobacco epidemic
The Medical Research Council (MRC) report in 1957 stated unequivocally that there was a link between smoking and lung cancer. We also know smoking is the leading cause of COPD.
Not starting smoking in the first place will prevent many cases of COPD; giving up will improve symptoms and is the most effective treatment for the condition.
In the last 70 years, the number of people smoking in the UK has come down as governments have slowly implemented tobacco control policies.
Astonishingly, the first UK tobacco control plan was not published until 1998 – more than 40 years after the MRC’s warning.
However, there is still a big issue with smoking and inequality. The 17 per cent of people who still smoke in the UK are more likely to be poor, have received less education, and have a greater likelihood of suffering from mental health problems. The most socially deprived men in England can expect to live to 73, compared with 83 among the wealthiest.
Roughly 50 per cent of the difference in life expectancy between rich and poor is due to smoking.
Smoking is based on an addiction that for most people starts in childhood, so stopping children from starting to smoke is a very high public health priority.
One of the things we have been doing at Royal Brompton & Harefield NHS Foundation Trust, is to gather evidence to try to bring about changes in policy. For example, our study published in Thorax about smoking uptake in children, showed about 200,000 11 to 15 year olds were taking up smoking each year in the UK. This underlined how smoking should be thought of as a child protection issue.
The research was cited in Parliament as evidence to support measures including the ban on smoking in cars with children, and standardised packaging, which came into force last year.
For people who do smoke, we now have the problem that reduced funding to local authorities means they are being forced to cut smoking cessation services.
I would like to see these funds ring-fenced for evidence-based treatment combining psychological support and pharmacological therapy - dual nicotine replacement or newer anti-smoking medications such as Varenicline. A “polluter pays” levy on tobacco industry profits could be used to cover any shortfall in funding.
Research has shown that pulmonary rehabilitation – physiotherapist-led exercise and education can provide real benefits for those with COPD.
Pulmonary rehabilitation makes breathing easier and helps with fatigue. It also helps patients feel more positive about their health.
My colleague Professor Anita Simonds’ textbook on pulmonary rehabilitation, published in the mid-nineties was something of a trailblazer, showing the real benefits it can offer patients.
Muscle weakness and deconditioning is big problem for people with long term respiratory conditions.
If people are less fit they get breathless more easily. Our research has shown that physical activity levels are reduced even in people with early COPD, and worked with European colleagues to develop better ways to measure and improve it. We need a range of strategies to improve this alongside pulmonary rehabilitation. Professor Michael Polkey has shown similar benefits with Tai Chi.
Singing for Breathing aims to enhance existing physiotherapeutic support for respiratory conditions by introducing patients to a new form of enjoyable, informal exercise.
Our research shown this to have a beneficial effects on patients. Since our original project here, and with the backing of the British Lung Foundation, there are now over 70 singing for lung health groups across the UK.
Lung volume reduction for COPD
Within the last 70 years, respiratory experts have looked at lung reduction to reduce symptoms of COPD.
Reducing the amount of space in the lungs may seem counter-intuitive, but emphysema causes lung tissue to break down, causing what should be springy, elastic tissue to become baggy, floppy and inefficient – the result is the lung fills up with air but doesn’t empty.
In some patients, the emphysema affects one part of the lung more and the rest of the lung is relatively preserved. The damaged part gets in the way of the rest of the lung. So, if you can get rid of the damaged tissue, the remaining lung can works more effectively and breathing is easier.
Over the last 20 years, Royal Brompton Hospital has pioneered surgery and innovative approaches for COPD and other respiratory problems.
Professors Duncan Geddes and Peter Goldstraw undertook the first randomised control study showing there was a benefit for patients with COPD of at least up to a year with surgery versus non-surgical medical care.
The operation to reduce patients’ lung volume has been refined and is safer and more effective than ever.
One of the ideas that came out of the original research, was that rather than cutting away the damaged parts of the lung, they could instead be blocked off with valves, placed using a fibre-optic camera called a bronchoscope, causing them to collapse. The damaged lung would still be in the chest, but emptied of air, it wouldn’t get in the way of breathing and would simply shrink away.
We published the first case series of this approach using lung volume reduction with endobronchial valves in 2003. We have now gone on to show that this bronchoscopic approach is effective in randomised controlled trials and are currently running the CELEB trial comparing valve placement and the classic surgical approach directly.
Our team, including Professor Pallav Shah and Dr Sam Kemp are also evaluating a range of other bronchoscopic treatments including lung volume reduction coils and approaches that target the nerves in patients’ airways.
We are also leading the UK Lung Volume Reduction Trial Network supported by the British Lung Foundation which is collecting all the data from different centres which carry out these procedures.
Although only a proportion of patients are suitable, lung volume reduction is a huge leap forward for people with emphysema .
The fact that NICE has now approved endo-bronchial valve treatment will lead to a change in the way COPD is looked at.
This is good news, because there has been an attitude that not much could be done for COPD, so it got a little forgotten about.
The challenge now is to raise awareness that these procedures are available, that they are safe, and that they work.
Perhaps one of the most important improvements for those with COPD, has been non-invasive ventilation, which has transformed the outlook for patients admitted to hospital with very severe attacks casing respiratory failure.
I have witnessed non-invasive ventilation making a big difference to patients during the course of my career.
When I qualified in the 1990s, patients with severe emphysema would come to hospital with an acute exacerbation (a sudden worsening of COPD symptoms). They wouldn’t be able to breathe unaided and would often die.
The introduction of non-invasive mask ventilation at Royal Brompton by Professor Anita Simonds meant that many of these patients were able to recover from these acute episodes. On average, non-invasive ventilation has been shown to reduce the risk of dying by 46 per cent and the risk of needing intubation was reduced by 65 per cent.
There are an estimated 1.3 million with COPD in the UK, so treatments have the potential to help a huge amount of people.
While it’s not responsible for all cases of COPD, we mustn’t lose sight of the fact that smoking remains the leading cause of the disease, and further work is needed to bring smoking rates down further.
In terms of treatment and therapies, things have hugely improved in recent years – and there are ongoing advances. I’m sure the teams at Royal Brompton Hospital will continue, with our colleagues and peers around the world, to be at the forefront of these.